Infectious Diseases in Critical Care Medicine

Table 10

Treatment for Adults (

Continued

)

Pathogen

Initial treatment prior to availability of susceptibility

Viral hemorrhagic fevers [filoviruses

(e.g., Ebola, Marburg) andarenaviruses (e.g., Lassa, Machupo)]

Supportive therapy and ribavirin.

Rabies

Supportive care. The “Milwaukee Protocol” (see “Selected Pathogens”).

Category B pathogens

Brucellosis (

Brucella

species)

Doxycycline 100 mg PO b.i.d. (6 wk) plus gentamicin (7 days)

or

doxycycline as above plus streptomycin 1 g IM daily for 2–3 wk.

Alternative therapy: doxycycline as above plus rifampin 600–900 mg PO daily for 6 wk or doxycycline plus cotrimoxazole (160 mg

trimethoprim) po qid for 6 wk.

Meningitis has been treated with trimethoprim-sulfamethoxazole, rifampin, and doxycycline.Alternative therapy or treatment for pregnant patients: Trimethoprim (6–8 mg/kg/day/sulfamethoxazole (40 mg/kg/day) IV in one or

two divided doses followed by the same dose PO

plus

rifampin 10–15 mg/kg/day in one or two doses followed by 600–900 mg PO

daily for 6 wk.

Epsilon toxin of

C. perfringens

Supportive care.

Food safety threats (e.g.,

Salmonella

spp.

, E. coli

O157:H7,

Shigella, Vibrio

spp.

,L. monocytogenes, C. jejuni, Y.

enterocolitica

)

Specific antimicrobial therapy as outlined in standard texts.

Glanders (

Bk. mallei

)

Septicemic disease is treated intravenously for 2 wk followed by oral therapy for a total of at least 6 mo. Pulmonary disease requires

6–12 mo total therapy. Other severe disease requires 20 wk therapy combining IV and oral medications. Doxycycline plusimipenem recommended for the treatment of severe cases.

Melioidosis (

Bk. pseudomallei

)

Consistently susceptible to imipenem. Good in vitro activity for doxycycline and minocycline. Ceftazidime effective but rare isolates

have been resistant. Meropenem also recommended for treatment. Amoxicillin/clavulanate, piperacillin, and piperacillin/tazobactam probably effective.

It should be noted there is a disparity

between MICs and susceptibilitytesting by disc diffusion and clinicalresponse. Time-kill studies, animalresponse, and clinical experiencenecessary to validate the use of otherantibiotics that show susceptibility.

All isolates resistant to aminoglycosides, clindamycin, and erythromycin. Intermediate or highly resistant to amoxicillin, ticarcillin,

cefoxitin, cefoperazone, cefsulodin, aztreonam, cotrimoxazole, azithromycin, chloramphenicol. 50% of isolates intermediate orresistant to ciprofloxacin, pefloxacin, ofloxacin, and norfloxacin. Quinolones deomonstrate poor efficacies for preventing relapsesand are not recommended for treatment or prophylaxis.

Psittacosis (

C. psittaci

)

Doxycycline 100 mg PO b.i.d. for 10–21 days. Azithromycin, chloramphenicol, and selected quinolones may be alternatives.

470 Cleri et al.